Tobacco Cessation Flashcards
pack year smoking history formula
PY = cigarettes/day x years smoked
what is the 5 a’s model
ask about tobacco use ( every visit)
advise to quit
assess willingness to make attempt to quit
assist in quit attempt (behavioral therapy, meds, or motivational interviewing to encourage future attempt)
arrange follow up (fu within week for pt willing to make quit attempt, fu at next visit if unwilling)
1800QUITNOW Is the national hotline
medications should be encouraged along with counseling/behavioral therapy in all pts attempting to quit unless contraindicated
first line:
5 nicotine replacement therapies (NRT): patch, gum, lozenge, inhaler, or nasal spray (short acting, except long acting)
2 non nicotine drugs : bupropion and varenicline (long acting)
combining a short acting NRT with a long acting patch is most effective at reducing cravings. ex: patch with bupropion SR or patch with lozenge
EVALI
e cigarrete/vaping product associated lung injury
behavioral counseling is preferred over medications for pregnant women, adolescents, smokeless tobacco users, and light smokers
smokers who quit no longer have the CYP1A1 inductions, so they experience supratherapeutic levels of normally dosed theophylline, fluvoxamine, caffeine, olanzapine, clozapine, and R-isomer (the less potent isomer of warfarin)
SMOKING INCREASES BLEEDING RISK ON CLOPIDOGREL AND WARFARIN
women who smoke shouldn’t take estrogen containing oral contraceptives because
increases risk of CVD events
vaccines for smokers
if ages 19-64, they should get
pneumococal and influenza
nicotine patch (nicorderm CQ) otc
initial dose is based on # cigarettes smoked/day
SE: vivid dreams , skin irritation
highest adherance rate, but must remove before MRI
Nicotine inhaler (nicotrol)- use up to 6 months
nicotine nasal spray (nicotrol NS) - use up to 3 months
both Rx
this is for the fastest delivery , and is useful for rapid relief of withdrawal symptoms.
it also mimics the hand to mouth smoking action.
this has highest risk of dependence
Nasal spray SE: watery eyes, sneezing, transient changes in taste and smell
Inhaler SE:mouth and throat irritation, sinusitis
nicorette lozenge (nicorette mini)
nicotine gum (nicorette) otc
initial dose based on time to first cigarette after waking
these are sugar free.
do not eat or drink 15 minutes before or during use
how to use: chew slowly until there is a tingle or peppery flavor in mouth then park it between gum and cheek until tingle flavor goes away. when it goes away begin to chew and then repeat the steps until most of the flavor/tingle is gone.
explain time to cigarette after waking dosing regimen (for gum and lozenge) 12 wks
</= 30 minutes after waking –> 4mg every 1-2h for 6 weeks, then 4 mg q2-4h for 3 weeks then 4 mg q4-8 hours for 3 weeks
> 30 minutes after waking –> 2 mg q1-2 h for 6 weeks ,then 2 mg q2-4 h for 3 weeks, then 2 mg q4-8h for 3 weeks.
BEST to use >/= 9 pieces of gum per day in the first 6 wks
DO NOT EAT/DRINK 15 min before or during use. 4 MG strength helps to reduce or delay weight gain: acidic beverages/foods decrease the buccal absorption
explain dosing regimen for number of cigarettes/day. For the patch, used for 8-10 weeks
(1 pack = 20 cigarettes)
> 10 cigarettes/day -
21 mg for 6wks, then 14 mg for 2 wks, then 7 mg for 2 wks
</= 10 cigarettes/day
14 mg for 6 wks, then 7 mg for 2 wks
Warnings for NRT
avoid in immediate post heart attack period, life threatening arrhythmias, severe or worsening angina and pregnancy
inhaler/nasal spray: avoid in asthma, COPD, and other chronic respiratory diseases
SE of NRT
insomnia, HA, dizziness, nervousness, dyspepsia (indigestion)
FDA prohibits sale of nicotine products to ppl < 18
buproprion SR (zyban)
wellbutrin SR and XL are the depression/seasonal effective disorder brand names
blocks the reuptake of dopamine and NE. results in reduced cravings and withdrawal sx
dose: START AT LEAST 1 WK BEFORE QUIT DATE. SR- 150 QAM for 3 days, then 150 mg BID . max dose 300 mg /day. use up to 6 months.
BOXED warning for increased risk of suicidal behavior in children, adolescents, and young adults taking antidepressants
contraindications: seizures, hx of bulemia/anorexia, use with MOAi’s linezolid or IV methylene blue, abrupt discontinuation of ethanol or sedatives , do not use with other forms of buproprion
warnings: serious neuropsych events, mania, hypomania, HTN, angle closure glaucoma, rash (including SJS)
SE: dry mouth, insomnia (take 1st upon waking up and 2nd dose 8 hrs later to decrease), tremors, weight loss, agitation, anxiety, tachycardia, HA, sweating, N/V, constipation. delays weight gain,
discontinue if no progress by week 7
varenicline (chantix) moa
comes in starting month pack and continuing month pack
Tyrvaya (nasal spray for dry eyes)
partial neuronal alpha4, beta 2 nicotnic receptor agonist. causes low level stimulation of receptor while blocking ability of nicotine to bind. it causes low level stimulation of the receptor but prevents real nicotine from binding
relieves withdrawal sx and inhibits the surges of dopamine responsible for reinforcement/reward assoc. with real smoking
start 1 week before quit date.
days 1-3 use 0.5 mg daily
days 4-7 use 0.5 mg BID
day8 (quit date and beyond) use 1 mg BID
use for 12 weeks. could do 24 total to maintain success
CrCl,< 30 ml/min, used 0,5 mg daily titrated to max 0.5 BID
warnings: serious neuropathic events, depression, suicide ideation, seizures, increased effects of alcohol, sleepwalking (somnambuism, accidental injury, CVD risk, hypersensitivity rxns.
SE: nausea, insomnia, abnormal dreams, HA, constipation, flatulence, vomiting,
to reduce nausea, take after eating and drinking full glass of water, reduce dose prn
to decrease insomnia, take second dose earlier than bedtime.
if unable to quit on day 8 smoking. decrease the smoking by 50% in first 4 weeks, ,then quit another 50% during week 5-8 and quit by week 12.
not recommended for < 16
varenicline and bupropion dont need to be tapered when DCd
remember that pts on varenicline and bupropion need to start 1 week before quit date since the drug helps reduce withdrawal
if pt is concerned about weight gain and wants to quit
use gum, lozenge, and bupropion SR because they all delay weight gain
if pt has depression and wants to quit
use bupropion SR
it pt has dentures and wants to quit obviously avoid the gum
if pt has asthma or copd and wants to quit, avoid inhalers or nasal sprays
if pt has seizures and wants to quit avoid
avoid bupropion and varenicline
if pt has a skin condition and wants to quit obviously avoid the patch
counseling for nicotine patch
use new patch each day, save the pouch the patches come from to throw away the old patch (fold it first).
press new patch on clean dry hairless area for 10 seconds firmly
wear for 24 hrs esp. if cravings begin upon waking
can remove patch before bedtime (after 16 hrs) if having vivid dreams and apply new one in the morning.
never cut or wear multiple patches
rotate application site . each application spot should get a week break
how to use nicotine nasal spray
tilt head back slightly and spray once/nostril while breathing through the mouth
no inhaling through nose or sniffing or swallowing
never use more than one lozenge at a time or continuously use lozenges one after the other
varenicline and bupropion cause suicide ideation and insomnia
varenicline additionally causes nausea which can be improved with dose changes
reduce amount of alcohol intake while on varenicline because it can increase alcohols effects
